Aleisha Crista Matern Candidate. Dental Hygiene Department. This thesis is approved, and it is acceptable in quality and form for publication:

Aleisha Crista Matern Candidate Dental Hygiene Department This thesis is approved, and it is acceptable in quality and form for publication: Approved by the Thesis Committee: Demetra Logothetis, RDH MS, Chairperson Christine Nathe, RDH MS Diana Aboytes, RDH MS i

Local Anesthesia in Dental Hygiene Education By Aleisha C. Matern, RDH B.S., Dental Hygiene, University of New Mexico, 2009 THESIS Submitted in Partial Fulfillment of the Requirement for the Degree of Master of Science Dental Hygiene The University of New Mexico Albuquerque, New Mexico May 2013 ii

DEDICATION I dedicate this thesis to: First and foremost my parents, David and Romona Barnaby, who always challenged me to continue further in my educational goals, and supported me through their love and prayers. My husband Matthew, for his continued support, encouragement, and love. You and only you, forever and ever, promise promise. and To my first employer L. Paul Balderamos, DDS MS for his willingness to teach me and mold me into a healthcare provider that is always striving to improve myself and my skills and for fully supporting and promoting my desire to continue in my dental hygiene education. iii

ACKNOWLEDGEMENTS I would like to thank my thesis committee: Demetra Logothetis, Christine Nathe, and Diana Aboytes for their guidance in my undergraduate and graduate career and in the development of this research project. Your many hours of instruction and review during these many years have been invaluable. iv

Local Anesthesia in Dental Hygiene Education By Aleisha Matern B.S., Dental Hygiene, University of New Mexico, 2009 M.S., Dental Hygiene, University of New Mexico, 2013 ABSTRACT Purpose: The purpose of this study was to determine the following: 1. What is the level of education in local anesthesia/pain control courses for dental hygiene programs in the United States. 2. Does the level of local anesthesia/pain control education have a direct correlation to the level of degree offered at its respective program? 3. Is there a need to develop a nationally recognized standard for local anesthesia/pain control courses in dental hygiene programs? Methods: A survey was sent via an online survey distributor to dental hygiene programs in the United States. The participants in this survey were either the main instructor for their program s local anesthesia/ pain control course, or for those whose program did not offer such a course in their curriculum the director of the program was the participant. Results: The results of this study suggest that the vast majority of instructors of local anesthesia/pain control courses, as well as the directors of dental hygiene programs of schools who do not offer such programs, both agree that the education of dental hygiene students in local anesthesia/pain control is very important. When comparing the percent of competency an injection is taught to in the v

clinical portion of a local anesthesia/ pain control course vs. the level of education the respective program offered, a direct correlation was not found. In fact, both associate and bachelor programs alike rated that the most common percentage that their courses require a student to reach was a 75-79% competency level. Discussion: It is the researcher s opinion, that the requirements for local anesthesia/ pain control education across the board should be standardized, as well increased, to a stricter level. This not only would help to increase the level of knowledge a dental hygiene student possesses upon licensure, but also raises the bar for dental hygiene as an established discipline. vi

Table of Contents List of Figures... ix Chapter I: Introduction... 1 Introduction...1 Statement of the problem...1 Significance of the problem...2 Operational definitions...4 Assumptions...6 Limitations...6 Methodology...7 Chapter II: Literature Review... 8 History of local anesthetics...8 Physiology and pharmacology of local anesthetics...9 Vasoconstrictors and local anesthesia...10 Types of local anesthetics used in dentistry...10 Complications associated with the administration of local anesthesia...12 Local anesthesia in dental hygiene...12 Regulations governing the administration of local anesthesia in dental hygiene..14 The importance of dental hygienists having an in depth knowledge of local anesthesia...16 Chapter III: Methods and Materials... 18 Research design and procedures... 18 Chapter IV: Results... 20 vii

Chapter V: Discussion... 37 Appendices:... 39 Appendix A: HRPO approval letter... 39 Appendix B: Informed consent cover letter...40 Appendix C: Survey Monkey survey...41 Appendix D: Local anesthesia administration by dental hygienists state chart...50 References:... 53 viii

List of Figures Figure 1: States that allow the practice of local anesthesia by an RDH...20 Figure 2: Scope of practice for a licensed RDH with a local anesthesia license/certificate...21 Figure 3: Pain management courses that do NOT include the administration of local anesthesia...22 Figure 4: Programs that offer a local anesthesia course in their curriculum...22 Figure 5: State requirements for local anesthesia licensure...23 Figure 6: Accelerated course...23 Figure 7: Course taught by a contracted educator...24 Figure 8: Courses that require the use of a textbook...24 Figure 9: Textbooks used...25 Figure 10: Topics covered...26 Figure 11: Hours of class per week...27 Figure 12: Number of classes per week...27 Figure 13: Weeks per semester...28 Figure 14: Clinical/laboratory portion of the course...29 Figure 15: Structure of clinic/laboratory portion...29 Figure 16: Program s minimum requirements for administration on human subjects...30 Figure 17: Techniques taught in clinic/lab...30 Figure 18: Taught in clinic/lab to competency...31 Figure 19: Level of competency in %...31 Figure 20: Requirements to pass clinical/laboratory portion...32 Figure 21: If answered Yes to Q18, to what extent?...33 Figure 22: Participant s professional title...33 Figure 23: Participant s highest degree held in dental hygiene...34 Figure 24: Participant s highest degree held overall...34 Figure 25: Participant s number of years teaching this course...35 Figure 26: Number of students enrolled per graduating class...35 Figure 27: Highest level of education offered within the participant s program...36 Figure 28: Injections taught to competency in % VS. Education level offered in that program...36 ix

Chapter I Introduction In the United States the dental hygiene practice is governed by state law and the level of education required regarding local anesthesia varies greatly. Because of this division among states the reciprocity of local anesthesia training and licensure varies and can sometimes make practicing in another state from which you originated difficult. A dental hygienist who wishes to practice in another state, may require re-testing, continued local anesthesia education, or in the case where it is not currently legal to perform local anesthesia as a dental hygienist in a specific state, then the acknowledgement of previous local anesthesia training is null and void. This research is intended to identify how diverse the spectrum of educational requirements is among states and possibly identify educational needs and national reciprocity solutions. Statement of the Problem 1. What is the level of education in local anesthesia/pain control courses for dental hygiene programs in the United States? 2. Does the level of local anesthesia/pain control education have a direct correlation to the level of degree offered at its respective program? 3. Is there a need to develop a nationally recognized standard for local anesthesia/pain control courses in dental hygiene programs? 1

Significance of the Problem Many in the healthcare community consider dental hygiene to be the oral counterpart to the medical nurse. This concept originated when Dr. Alfred C. Fones developed the dental hygiene model to serve as an adjunct provider rendering preventive services to the community, where the term dental nurse became associated. However, Dr. Fones did not care for this term since nurses were generally associated with caring for those with disease, and dental hygienists were intended to be associated with treatment intended for disease prevention. It was at this time that he coined the term Dental Hygienist, which has continued as the identifier for the past century. 1 Since its inception, dental hygiene has grown and evolved into a multifaceted profession. Not only do dental hygienists provide preventive services to their patients, they also educate about various disease processes, as well as provide therapeutic methods when disease has already occurred. The roles of a dental hygienist include: clinician, educator, oral health promoter, researcher, change agent, manager, and client advocate. 1 Currently dental hygiene is not considered to be a discipline like its medical counterpart, but rather a field of study. Many dental hygienists, and dental hygiene advocates have worked diligently over the years for the profession to achieve greater skill sets, respect, and autonomy. Though it has been a slow journey, and one that is not near its end, dental hygiene has achieved great strides in becoming a more respected profession, and this will hopefully result in dental hygiene ultimately becoming a distinct discipline. Research indicates that although dental hygiene has achieved great strides in becoming a discipline, for example developing a metaparadigm, it has yet to build a substantial research body of knowledge built upon conceptual and theoretical models. 2 2

Though dental hygiene as a collective often disagrees with this statement, it will not be until the profession can prove itself worthy of the title that it will be able to elevate itself as a recognized discipline. Dental hygiene as a field of study has gone through many obstacles since its birth in the early 1900 s to bring about greater recognition among its fellow healthcare counterparts. Since then over 100 years of practice has passed and with it many new laws and regulations which have broadened a dental hygienists skill set and scope of practice. 3 Included in this was the administration of local anesthesia which was introduced into the field of dental hygiene in the early 1970 s in the state of Washington, followed shortly thereafter by New Mexico. Local anesthesia is a very complex subject requiring students to have an in- depth understanding of head and neck anatomy, physiology, pharmacology, technical skills, and a good chair side manner. Because of potential side effects, the risk of administering local anesthesia to the patient is much higher than other dental hygiene procedures, which makes the level of competency when administering local anesthesia crucial to protecting the patient s health and safety. 4 These factors naturally result in a need for the highest level of education to be attained in an educational setting, and a continual reevaluation of current standards. Although the information regarding local anesthesia in dental hygiene education is accessible to the public through course outlines, curriculum descriptions, and state regulations, there is currently not any comprehensive data compilation on this subject. By gathering all of this data into one place, the goal is to better understand what the nationally accepted standard of education is on the subject. Also, if the standard is 3

lacking, perhaps this can encourage programs to raise their standards, and bring about a national awareness on the importance and need for exemplary educational practices; thereby continually improving this field of practice. Operational Definitions CODA: Commission on Dental Accreditation, which is part of the American Dental Association, is responsible for accrediting all dental and associated programs in the US. This organization is nationally recognized by the United States Department of Education. The mission of CODA is to serve the public by establishing, maintain, and applying standards that ensure the quality and continuous improvement of dental and dentalrelated education and reflect the evolving practice of dentistry. Direct Supervision: The supervising dentist must be available for consultation regarding approved procedures in accordance with the diagnosis and treatment plan and must remain physically present throughout the performance of the procedure. General Supervision: The supervising dentist must be available for consultation regarding approved procedures in accordance with the diagnosis and treatment plan, but is not required to be on the premises during the execution of the procedure. Indirect Supervision: The supervising dentist must be available for consultation regarding approved procedures in accordance with the diagnosis and treatment plan and must remain on the premises throughout the procedure. However, the supervising dentist is not required to be physically present. Local Anesthesia: Loss of sensation in a circumscribed area of the body as a result of the depression of excitation in nerve endings or the inhibition of the conduction process in peripheral nerves. 4

Metaparadigm: A set of concepts and propositions that form the basis for the development of a discipline. A metaparadigm is the most general statement of a discipline and functions as a framework in which the more restricted structures of conceptual models develop. NERB: North East Regional Board of Dental Examiners was founded in 1969 to facilitate the licensure process for candidates and eliminate the need for repetition of state board clinical examinations. NERB is comprised of 16 state dental boards. Nitrous Oxide-Oxygen Analgesia: Nitrous Oxide delivered in combination with Oxygen is an inhalation method of conscious sedation. This process relaxes individuals who are mildly apprehensive about dental experiences and provides pain control for procedures that are slightly or moderately painful. NSPT: Non- surgical periodontal therapy, also known as scaling and root planing, involves the careful cleaning of the root surfaces to remove plaque and calculus from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins. This is followed by adjunctive therapy such as local delivery antimicrobials and host modulation, as needed on a case-by-case basis. RDH: Registered Dental Hygienist. A licensed oral healthcare professional who integrates the roles of clinician, educator, consumer advocate, manager, change agent, and researcher to prevent oral disease and to promote health. WREB: Western Regional Examining Board. Developer and administrator of reliable competency assessments for dental health care providers and state agencies which license dental professionals. WREB is comprised of 16 member states and 16 affiliate/ non member states accepting WREB results. 5

Assumptions It is assumed that the participants surveyed in this study are all employed at an accredited dental hygiene program within the United States and are the head instructors for their program s local anesthesia/pain control courses, or in the case where a local anesthesia/pain control course is not offered then the program director was the person who completed the survey. It is also assumed that each participant answered the questions presented in the survey fully and honestly to the best of their abilities. Limitations The number of accredited dental hygiene programs located in the United States is roughly 300 in number. Though each state may be represented in this study, each level of education may not be, depending on the amount of participants and responses received back. This limits the study in that not all opinions may be accurately represented as it would be should all of the schools participated. During the collection of emails for each program from the ADHA s list of schools, some schools did not have a contact email listed, therefore they were excluded from this study. The amount of literature published on this subject is very minimal. This was a driving factor in conducting this research; however it made gathering sufficient data for the literature review difficult. 6

Methodology The methodology regarding this study involved the development of a survey including multiple choice and fill in the blank test items. These items were based on educational regulations and requirements for local anesthesia in dental hygiene education. Upon approval by the thesis committee and the Human Research Protection Office, it was loaded onto Survey Monkey, an online and interactive survey distributor. It was then sent via email to the head instructors of the local anesthesia/ pain control courses at each dental hygiene school in the country. Once the data were received, a statistician analyzed the information into a quantifiable and qualitative data set. 7

Chapter II Literature Review History of Local Anesthetics The discovery of local anesthetics occurred around 1850 with the use of cocaine by way of the coca leaf. The first recorded operation using local anesthetics was in 1884, with the use of cocaine on the eye of a glaucoma patient. Soon after discovering the beneficial properties of local anesthetics, their use in surgeries spread quickly in Europe and America. 5 Interestingly, the first successful documentation of a nerve block with the use of local anesthesia was achieved in a dental setting by a dentist from New York named Dr. Nash. Nash used 0.5 ml of 4% cocaine hydrochloride to block the infraorbital plexus in order to obturate a maxillary incisor, which involves the filling of a root canal. The second successful documentation was by Dr. Halsted who completed a block on the inferior alveolar nerve of his dental student. Dr. Halsted and his colleague Dr. Hall, whom published the original article on Dr. Nash, went on to develop nerve and regional blocking techniques. 6 However, through trial and error the toxic effects of cocaine became apparent resulting in many deaths and addictions. In a 7 year span, starting with the use of cocaine in the first ophthalmic surgery in 1884, 13 deaths were reported and over 200 cases of systemic intoxication. It was not until 1891 that the pure synthesized form was created, and thus the administration and enhancement of local anesthetics began. 6 Between 1891 and 1930 many ester anesthetics were synthesized including benzocaine, and from 1898 to 1972 most amide anesthetics were created. Since then only one other amide has been 8

introduced into the market, ropivacaine. Because of the extensive research that went into creating this new anesthetic, ropivicaine has very low side effect rates. 7 Physiology and Pharmacology of Local Anesthetics Local anesthetics are often used to suppress pain in a circumscribed area of the body. This suppression occurs when the depolarization within the nerve conduction process is restricted. Depolarization results when there is a rapid influx of sodium ions into the nerve membrane, causing the transmission of a nerve impulse, thus resulting in a pain response. However, local anesthetics inhibit this pain response by effectively competing for, and binding to the specific sodium receptor sites along the nerve membrane. 8 Local anesthetics are produced in two chemical forms, esters and amides. Esters are metabolized in the blood through plasmacholinesterase, whereas amides are metabolized in the liver; with the exception of prilocaine which is metabolized primarily in the lungs with only a small portion being metabolized in the liver and articaine which is metabolized primarily in the blood, much like an ester, and a small portion in the liver. Esters and amides differ in that esters do not contain a nitrogen ion in their intermediate chain, whereas amides do. Ester local anesthetics are also more likely to cause acute allergic reactions do to the fact that they are derived from PABA, para -aminobenzoic acid. Amides are not derived from this compound and are therefore less likely to cause an allergic reaction. Due to the high rate of acute allergic reactions associated with PABA derivatives, injectable ester local anesthetics, such as procaine, are no longer used in the United States. 9 9

Vasoconstrictors and Local Anesthesia Vasoconstrictors are used to constrict blood flow by binding to both the alpha 1 and alpha 2 adrenergic receptor sites of the sympathetic nervous system. When vasoconstrictors are added to local anesthetics they counteract the vasodilatory properties of the local anesthetic and produce many favorable effects, including increased hemostasis and duration of the local anesthetic, as well as decreased toxicity rates and dosage levels. 10 However, these effects also come with increased vasopressor effects, as well as prolonged anesthesia past the duration of the procedure they were intended for. 11 Vasoconstrictors that are used with each local anesthetic vary by concentration as well as type. Vasoconstrictors used in local anesthetics come in concentrations of 1:20,000 levonordefrin and 1:50,000, 1:100,000, and 1:200,000 for epinephrine. 12 However, more concentrated dosages are used in emergency situations outside the realm of local anesthetics for things such as anaphylaxis, and generally come in concentrations of 1:1,000, or 1:10,000 epinephrine. 8 Types of Local Anesthetics Used in Dentistry Around 1904, Dr. Alfred Einhorn synthesized the first local anesthetic used in dentistry. This anesthetic was an ester derivative and was called procaine, or more commonly known to patients at novacaine. Its use in dentistry continued for the first part of the 20 th century. By 1943, lidocaine had been discovered and proved to have much greater analgesic qualities than procaine, but was contrastingly much safer in its effect. 8 From that point on, the field of dentistry adopted lidocaine as its primary anesthetic of 10

choice; however there are still many other anesthetic choices available to use depending on what is best for the patient s treatment needs. Many different types of local anesthetics are used in dentistry, and their use is dependent on their duration of action, metabolization route, and what kind of affect they might have on a patient s health status. Local anesthetics can come in short, intermediate, and long acting duration and may or may not contain a vasoconstrictor. The following groups are broken down into their respective lengths of duration: short acting-prilocaine 4%, lidocaine 2%, and mepivacaine 3%; all without vasoconstrictors. Intermediate acting- lidocaine 2%, articaine 4%, prilocaine 4%, and mepivacaine 2%, all containing vasoconstrictors. Long acting-bupivicaine 0.5%. However, prilocaine 4% plain can also be an intermediate acting local anesthetic when it is given in a block injection. It can provide up to 60 minutes of pulpal anesthesia, whereas when given in an infiltration it will be short acting at around 30-40 minutes. 13 Topical anesthetics are also used and come in both amide and ester forms. The most common forms used are lidocaine 5% which is an amide, and benzocaine 20% which is an ester. Because benzocaine is in topical form and not being injected into the soft tissue, there is a lesser chance of it causing an acute allergic reaction as may be experienced with the injectable form. 8 This is because topical benzocaine remains primarily in it s base form making absorption into the cardiovascular system very slow, and therefore toxicity is unlikely in therapeutic doses. However, acute allergic reactions can still occur for those who have a sensitivity to esters, in which case an amide topical anesthetic would be the preferred choice. 13 11

Complications Associated with the Administration of Local Anesthesia With each new clinical skill learned come associated risks to both the patient and clinician. In regards to local anesthesia these risks are particularly more hazardous than many other procedures performed in a dental setting. These risks are as follows: Pain on injection, burning on injection, needle breakage, trauma to the soft tissue, trismus, hematoma, infection, edema, tissue sloughing, postanesthetic intra oral lesions, persistent anesthesia or paresthesia, and facial nerve paralysis. 13 Some of the previously mentioned complications would be considered more of an inconvenience by most, but others are more serious, such as persistent paresthesia, infection, or nerve paralysis. By following protocol and using proper techniques most of these complications can be avoided. Yet, if these situations do arise, it is imperative that the administrator is prepared and capable of handling such occurrences. 14 Local Anesthetics in Dental Hygiene In the early 1970 s, dental hygienists first became able to administer local anesthesia in the state of Washington, followed shortly thereafter by New Mexico. Since then, 44 states have made this skill a part of a dental hygienist s scope of practice. 3 Though the rules and regulations under which hygienists are allowed to practice local anesthesia vary from state to state, this addition to their skill set has become an invaluable part of the dental practice. Since the addition of local anesthetics to the dental hygiene practice, dental hygienists have gained a greater amount of independence in their own practice and treatment of patients. This differs from past circumstances in which dental hygienists 12

required a dentist to perform local anesthesia on their patient when treatment dictated. With a certification in local anesthesia the dental hygienist is able to perform necessary pain control measures without the time constraints previously placed on them while waiting for a dentist to complete the task. 15 When a dental hygienist administers local anesthesia, the type of supervision required varies by each state. Dentists must provide either direct supervision, indirect supervision, or general supervision; also known as unsupervised practice in the state of Oregon. The most ridged of these levels is direct supervision; however indirect supervision is the most common among the states. According to the ADHA, as of 2012 there are currently only 7 states that allow the use of general supervision. 16 The administration of local anesthesia can be beneficial for a combination of reasons. For example, a patient who is in need of non-surgical periodontal therapy will in most cases require the use of local anesthesia to reduce discomfort, as well as provide homeostasis. 13 In combination, this allows the dental hygienist to perform the procedure without hesitation of causing the patient further discomfort, and the homeostasis provides a clearer field of vision while performing the procedure itself. Many patients have an aversion to local anesthetic injections. These fears tend to concern pain during the injection, as well as pain during the dental procedure to follow if there is a lack of profound anesthesia 17. These apprehensions can be reduced, if not completely eliminated, with the use of proper technique. The previously mentioned conditions are most likely to occur when the injection is given too quickly or the correct dosage is not administered. These instances of poor technique generally arise when the administrator does not have sufficient time to complete the injection or tailor the dosage 13

and injection to the patient s specific needs. 18 By maintaining proper technique and adhering to the protocols given for minimal discomfort to the patient, the administrator will be able to provide a much more pleasant dental experience; thereby decreasing neglected treatment needs by the patient. 17 Regulations Governing the Administration of Local Anesthesia in Dental Hygiene In the United States, local anesthesia administration by the dental hygienist is regulated by various agencies. These agencies are located on both a regional and state level. According to the Local Anesthesia Administration by Dental Hygienists State Chart, (Appendix D) provided and compiled by the American Dental Hygienist s Association, only the regional agencies NERB and WREB require local anesthesia board exams for their members. However, NERB requires a written exam, whereas WREB requires both a written and clinical exam. Each state determines which boards, if any, they are members of, as well as how many. Furthermore, they may also be affiliates of boards, in addition to non-members that accept credentialing from other boards. 19 Beyond regional testing each individual state is able to require its own examination, either through the original local anesthesia course, or by approved state exam. Yet still, many states do not require any formal testing beyond the classroom to practice local anesthesia. This is because each individual state determines their own practice acts for licensed dental hygienists within their state. For example, if two states are members of the same regional board, their individual regulations are unique to their own state. These regulations are implemented through rules or statutes. Statutes are a part of the legislation practice act and are not easily changed. Rules have the same power of 14

the law, but are easily modified and can be delegated to a board to oversee their authority. 20 For more information regarding each state s specific local anesthesia requirements please refer to Appendix D labeled Local Anesthesia Administration by Dental Hygienists State Chart. Aside from the legal regulations, CODA is the agency responsible for the accreditation of all dental and dental related programs in the country. This agency governs the educational standards of each program. In order to obtain licensure in local anesthesia one must have graduated from an accredited dental hygiene program and successfully completed an approved local anesthesia course. However, it is not required that the local anesthesia course be taken at the program from which the dental hygienist graduated. Some programs do not offer a local anesthesia course within their program itself and therefore must either bring in an auxiliary instructor to come and teach an accelerated course, or the student must travel to an approved course; this course may be located out of state. 21 Licensure requirements for local anesthesia vary by regional board and state requirements. The most intensive not only require the successful completion of an approved local anesthesia course prior to testing, but also require a successful written and clinical board examination before application for licensure is accepted. Other options include a combination of successful completions of a local anesthesia course, and/or clinical or written exam. Some states do not require any state or regional examination before licensure is granted; however all states that do grant licensure require successful completed of an approved local anesthesia course. 15

The Importance of Dental Hygienists Having an in Depth Knowledge of Local Anesthesia Although not all states have the same standards for local anesthesia courses, or even allow licensure for dental hygienists, it is important that dental hygienists still maintain an in depth knowledge of local anesthesia. The reasons for this are multiple. In most scenarios a dental hygienist practices alongside a dentist. Whether or not a dental hygienist is licensed to practice local anesthesia does not mean they will not encounter patients who have had local anesthesia, or who will in the future; in fact, it is a certainty that they will. Due to this inevitably, it is important for the dental hygienist to be prepared to handle any situation that may arise alongside the administration of local anesthesia, as well as be well versed in the subject so as to answer any pre-procedural questions the patient may have. 22 Many times in a dental practice it is the dental hygienist who first treats the patient. Typically they will complete all charting, exams, and prophylactic work needed and then review treatment needs with the dentist. In many cases it is the dental hygienist s role to follow up and present the treatment plan to the patient that was developed by the dentist during their comprehensive exam. It is inevitable that patients will have questions regarding treatments proposed, specifically details of the procedure. In many instances this includes the discussion of local anesthesia injections regarding patient apprehension, possible allergic reactions, and any past adverse side effects. 23 The dental hygienist must take on multiple roles in this situation. Not only are they the patient s clinician, but they are an educator, counselor, collaborator, and patient advocate as well. They must educate the patient on the risks and benefits of using local anesthesia, try to calm any fears or apprehension the patient may be having, collaborate with the 16

dental staff in order to get recommended treatment scheduled and completed, and also continually advocate for the patient when recommended treatment may need to be modified, in order to meet a patient s specific needs. 1 Local anesthesia is considered an expanded function in the realm of a dental hygienist s scope of practice. Since the addition of local anesthesia in the 1970 s, there have been multiple functions that have become available to dental hygienist in the past 40 years. Included in these is the administration of nitrous oxide, carving and finishing of restorations, placement and removal of temporary fillings, crowns, and periodontal dressings, suture removal, and approval of sealant placements; with more expanded functions going under consideration and added yearly. 24 The addition of local anesthesia helped to pave the way for dental hygienists to become more educated and independent in their practices. They are able to utilize their extensive knowledge and education in a broader way, all while maintaining a collaborative relationship with dentists. This helps to meet the needs of the underserved populations in a way far greater than ever before in the history of dental hygiene practice. 25 17

Chapter III Methods and Materials Research Design and Procedures A research study was developed using a survey to evaluate the educational standards of local anesthesia in dental hygiene education. The survey was developed using multiple choice questions as well as fill in the blank. Once the survey was completed it was sent to UNM s Human Research Protection Office for exempt status approval on November 13 th, 2012. On November 19 th, 2012 the submitted survey was granted exempt approval. The survey was then entered into Survey Monkey, an online and interactive survey distributor, on November 26 th, 2012. A total of 319 potential participants received an email invitation containing a consent form cover letter and a link to access the survey at Survey Monkey s direct site. The participant s email addresses were obtained through the American Dental Hygienist Association s PDF list of current dental hygiene programs in the US. Those schools who did not list a contact email were excluded from this study. The inclusion criteria for completing this survey was that the potential participants be the main instructor for their dental hygiene program s local anesthesia/ pain control course, or if their program did not offer such course then their program s director was to answer any applicable questions in the survey. A reminder email was sent out to the potential participants one month after the opening of the survey, and then again at the two weeks, and one week mark before the closing of the survey. Once the data was collected through survey monkey and the survey was closed to any further participants on the deadline of January 31 st, 2013, it was then sent to Dr. Rick Ott, PhD, a statistician at 18

Colorado Mesa University to review and analyze. The data that was extracted was analyzed using univariate analyses and was described by frequency distributions in the form of histograms and pie charts. 19

Chapter IV Results A total of 161 participants responded and started the survey, with 142 completing in full; which is 50.5% of the original potential participants. The following graphs represent the participant s actual responses to the questions posed in the online survey. In Figure 1, 86% of the 142 respondents answered, Yes, to the question, According to the dental hygiene practice act in your state, can dental hygienists administer local anesthesia? whereas only 14% answered No. There are only 6 states that as of yet do not allow the practice of local anesthesia by a dental hygienist. They are listed as follows: Alabama, Delaware, Georgia, Mississippi, North Carolina, and Texas. States that allow the practice of local anesthesia by an RDH 14% 0% Yes No Skipped question 86% Figure 1 In Figure 2, the participants were posed the following question, Q2. (A) If you selected "Yes" to question #1, what is in the scope of practice for a dental hygienist with local anesthesia licensure/certification in your state? Please check all that apply. 122 respondents answered this question, where 20 skipped it. Most likely those who skipped the question were participants whose state did not allow for local anesthesia to be 20

practiced by a dental hygienist. Of the total respondents 97.5% of them answered that Blocks and infiltrations were in their state s scope of practice for a dental hygienist, with the Administer and monitor nitrous oxide coming in 2 nd at 62.3%. Scope of practice for a licensed RDH with a local anesthesia license/certificate General anesthesia 0.0% Other (please specify) 1.6% Infiltrations only 13.1% % Figure 2 0 50 100 150 skipped question Monitor nitrous oxide only 17.2% Administer and monitor nitrous oxide 62.3% Blocks and infiltrations 97.5% In Figure 3, 141 respondents answered the question, Q3. Do you offer a pain management course that does not include the administration of local anesthesia? Only 27 or 19% answered Yes, where the majority answered No, at 80%. 21

Pain management courses that do NOT include the administration of local anesthesia 1% 19% Yes No Skipped question 80% Figure 3 Figure 4 illustrates that of 141 respondents, 119 at 84% answered Yes, that they do offer a local anesthesia course in their curriculum, and only 22 at 15% answered No, they did not offer such a course. Programs that offer a local anesthesia course in their curriculum 1% 15% Yes No Skipped question 84% Figure 4 22

The state requirements for local anesthesia licensure are given in Figure 5. This chart reveals that the largest state requirement is a Written regional board at 45.4% followed closely with Number of hours at 43.7%. Display clinical competence in LA was 3 rd at 37%, but surprisingly a clinical regional board came in 4 th at only 29.4%. State requirements for local anesthesia licensure Skipped question Number of injections 28.6% Clinical regional board 29.4% 1 Other (please specify) 33.6% Display clinical competence in LA 37% Number of hours 43.7% Written regional board 45.4% 0 10 20 30 40 50 60 Figure 5 Accelerated course 1 Skipped question Yes 23.8% No 76.2% 0 20 40 60 80 100 Figure 6 23

Figure 6 shows that 76.2% of the 122 respondents answered that their local anesthesia course is not accelerated, with 23.8% answering Yes, their program is accelerated. Similarly, Figure 7 shows that a vast 98.4% of these courses are not taught by a contracted educator, with only 1.6% responding Yes they were. Course taught by a contracted educator 1 Skipped question No 98.4% Yes 1.6% 0 20 40 60 80 100 120 140 Figure 7 Courses that require the use of a textbook 1 No 7.8% Skipped question Yes 92.2% 0 20 40 60 80 100 120 Figure 8 24

Figures 8 and 9 show that over 92.2% of local anesthesia/pain control courses require a textbook and that Malamed is the most commonly used at 62.2% with Bassett coming in second at 22.8%. This large difference is most likely due to the original publishing dates and continuing editions of each textbook. For example Malamed was originally published in 1980 and is now in its 6 th edition, whereas Bassettt was published in 2009 and Logothetis in 2012 and are both still in their 1st additions. The quality of each textbook s material was not a topic evaluated in this study. Textbooks used Logothetis 5.2% 1 Specific information not given 11.9% Bassett 22.8% Skipped question Malamed 62.2% 0 20 40 60 80 Figure 9 25

Topics Covered Legal considerations Complications Infiltration technique Block technique Armamentarium Pharmacology of Vasoconstrictors Pharmacology of Local Anesthetics Neurophysiology Anatomy of head and neck History of Local Anesthetics 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Review In-depth Figure 10 The topics taught in the courses are generally covered in-depth with only Anatomy of head and neck and History of local anesthetics being covered in review at 70% and 60% respectively, shown in Figure 10. Figures 11, 12, and 13 depict what the average amount of class time is spent in the local anesthesia/pain control courses and how those hours are broken down in the semester. The most common answers to these questions were 3 hours of class, 1 time per week, during a 16 week semester. 26

Hours of class per week 1 8 hr 7 hr 5 hr 4 hr 3 hr 2 hr 1 hr 0 5 10 15 20 25 30 Figure 11 Number of classes per week 1 3 classes 4 classes 2 classes 1 class 0 5 10 15 20 25 30 35 40 Figure 12 27

Weeks per semester 1 0 2 4 6 8 10 12 14 16 Figure 13 11 weeks 2 weeks 7 weeks 12 weeks 18 weeks 8 weeks 6 weeks 14 weeks 10 weeks 15 weeks 16 weeks The anesthesia/ pain control courses show that almost 100% contain a clinic/laboratory portion, and in those clinic/laboratory sessions it was very similar regarding the responses between the didactic portion being taught prior the clinical vs. the didactic being taught at the same time as the clinical. The didactic prior to clinical won at 51.3% with the latter coming in behind at only 47.8%. This data is shown in Figures 14 and 15. 28

Clinic/laboratory portion of the course 1 No 0.9% Skipped question Yes 99.1% 0 20 40 60 80 100 120 Figure 14 Structure of clinic/laboratory portion Other.9% 1 Clinical and didactic at the same time 47.8 % Didactic prior to clinical 53.1% 0 20 40 60 80 Figure 15 The requirements for a student to administer local anesthesia on a human subject was by passing an exam, this ranked at 63.2% amongst those who responded in Figure 16. 29

Program's minimum requirements for administration on human subjects 1 Student displays clinical competence 11.4% Other 56.1% Pass an exam 63.2% 0 20 40 60 80 Figure 16 Techniques taught in clinic/lab Mental/Incisive Gow Gates Long Buccal Lingual Inferior Alveolar Nasopalatine Greater Palatine Infraorbital Anterior Superior Alveolar Middle Superior Alveolar Posterior Superior Alveolar Supraperiosteal Yes No Figure 17 0% 20% 40% 60% 80% 100% Figure 17, 18, and 19 describe the techniques taught in the clinic/lab including which specific injections are taught, to competency, and to what level of competency. Figure 19 shows that the most common level of competency required to be attained by a student in order to pass is a 75-79%. This was followed next by the 90-95 and the 100% 30

Techniques range, however with a fairly large margin between them and the leading range of 75-79%. Taught in clinic/lab to competency Mental/Incisive Gow Gates Long Buccal Lingual Inferior Alveolar Nasopalatine Greater Palatine Infraorbital Anterior Superior Alveolar Middle Superior Alveolar Posterior Superior Alveolar Supraperiosteal Yes No 0% 20% 40% 60% 80% 100% Figure 18 Level of competency in % Figure 19 Mental/Incisive Gow Gates Long Buccal Lingual Inferior Alveolar Nasopalatine Greater Palatine Infraorbital Anterior Superior Alveolar Middle Superior Alveolar Posterior Superior Alveolar Supraperiosteal 0 5 10 15 20 25 30 35 Number of responses 31 100% 95-99% 90-94% 85-89% 80-84% 75-79% 70-74% 65-69% 60-64% 55-59% 50-54%

In Figure 20 the requirements to pass the clinical portion of the course are represented. Completing the didactic portion with a passing grade and completing a set number of injections came as the top two requirements at 91.2% and 92.1% respectively. Successfully completing a final exam came in at 77.9%. Reuirements to pass clincial/laboratory portion Other 10.6% Skipped question Successfully complete a mock board exam 27.4% 1 Complete a set number of clinical hours 69.9% Successfully complete a final exam 77.9% Completed the didactic portion with a passing grade 91.2% 0 20 40 60 80 100 120 Figure 20 Complete a set number of specific injections 92.0% Figure 21 is a graph in response to the question posed to school s whose programs do not offer a local anesthesia/ pain control course. The question was as follows, Although dental hygienists cannot legally administer local anesthesia in your state, do you feel that it is still important for a registered dental hygienist to be knowledgeable in this subject? The response to that question was a resounding Yes at 100%. Figure 21 asks to what extent should students should be knowledgeable when it comes to handling situations regarding local anesthesia. 32

If answered "Yes" to Q18, to what extent? Other 19.2% Being able to manage a patient who is numb 88.5% 1 Managing medical emergancies related to the administration of local anesthesia 92.3% 0 5 10 15 20 25 30 Figure 21 Knowing contraindications and potential side effects relating to the patient's medical health during and following the use of local anesthesia 96.2% Figures 22, 23, 24, and 25 are all in response to demographic questions pertaining to the participant themselves. Participant's professional title 1 Graduate Director 0.8% Instructor 6.1% Assistant Professor 6.1% Professor 8.4% Other (please specify) 9.2% Director 69.5% 0 20 40 60 80 100 Figure 22 33

Participant's higest degree held in dental hygiene 1 PhD 0.8% Certificate 3.9% Other 11.7% Associates 20.3% Masters 27.3% Bachelors 35.9% 0 10 20 30 40 50 Figure 23 Participant's highest degree held overall 1 Associates 0.0% Certificate 0.0% PhD 4.7% Bachelors 7.8% Other 16.3% Masters 71.3% 0 20 40 60 80 100 Figure 24 34

Participant's number of years teaching this course 1-2 yrs 3-4 yrs 5-6 yrs 7-8 yrs 9-10 yrs 1 11-12 yrs 13-14 yrs 15-19 yrs 20 or more yrs 0 5 10 15 20 25 30 35 Figure 25 Responses not given in a qualitative form Skipped question Figures 26 and 27 pertain to each school s own demographics including class size and highest level of dental hygiene education offered to the students. Number of students enrolled per graduating class 1 10-14 per class 15-19 per class 20-24 per class 25-29 30-34 35-39 40 or more Skipped question 0 10 20 30 40 50 Figure 26 35

Highest level of edudcation offered within the participant's program 3% 0% 0% 8% 1% Certificate Associates 18% Bachelors Masters PhD 70% Other (please specify) Skipped question Figure 27 Figure 28 shows the comparison between the level an injection is taught to competency vs. the level of education offered at that program. The chart shows that 75-79% is the most common level required to be reached by students. Injections taught to competency in % VS. Education level offered in that program 70-74% 75-79% 80-84% 85-89% 90-94% 95-99% Masters Bachelors Associates Certificate 100% Figure 28 0 5 10 15 20 25 36

Chapter V Discussion The goal of this study was to better understand the level of local anesthesia education in dental hygiene schools in the US, as well as to answer the following questions: What is the level of education in local anesthesia/pain control courses for dental hygiene programs in the United States? Does the level of local anesthesia/pain control education have a direct correlation to the level of degree offered at its respective program? Is there a need to develop a nationally recognized standard for local anesthesia/pain control courses in dental hygiene programs? The results of this study suggest that the vast majority of instructors of local anesthesia/pain control courses, as well as the directors of dental hygiene programs of schools who do not offer such programs, both agree that the education of dental hygiene students in local anesthesia/pain control is very important. When comparing the percent of competency an injection is taught to in the clinical portion of a local anesthesia/ pain control course vs. the level of education the respective program offered, a direct correlation was not found. In fact, both associate and bachelor programs alike rated that the most common percentage that their courses require a student to reach was a 75-79% competency level. One masters and one certificate program answered these questions in the survey and although their answers were both above the 85% mark, there were not enough responses from each respective population group to effectively make a generalization regarding those programs. In regards to the question posed Is there a need to develop a nationally recognized standard for local anesthesia/pain control courses in dental hygiene programs? seems to remain up for debate. As the data shows, the majority of dental 37

hygiene programs who offer local anesthesia/pain control courses only require a 75-79% competency level for passing injections. While this level may be above most standard grading systems on the collegiate level, dental hygiene programs tend to hold a higher standard for themselves and their students. Also, when it comes to state licensure requirements less than 50% of those who responded indicated that their state required a written regional board, and less than 30% required a clinical regional board. It has already been established that local anesthesia holds one of the highest potential risks of all the clinical skills a dental hygienist can possess without proper training and technique. By minimizing educational standards in any way, one only increases these potential risks. After reviewing the data received in response to the research survey, the following questions may have been beneficial to finding a more definitive answer to the question, Is there a need to develop a nationally recognized standard for local anesthesia/pain control courses in dental hygiene programs? Examples of such questions are: 1.What level do you feel your program s standards are at? 2. Do you think your program should raise its standards? 3. Do you think dental hygiene programs located in the United States as a whole should raise their standards? It is the researcher s opinion that in order for states who are still concerned or on the fence about whether or not to add local anesthesia to the scope of practice of dental hygienists in their state, the requirements across the board should be standardized, as well increased, to a stricter level. This not only would help to increase the level of knowledge a dental hygiene student possesses upon licensure, but also raises the bar for dental hygiene as an established discipline. 38

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APPENDIX B 40

APPENDIX C 41

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APPENDIX D 50

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